This document provides guidance on communicating with the health care team. It discusses the importance of open communication and outlines best practices for good communication, including using common language and being concise. It also describes the medical record/chart that documents a patient's condition and treatment over time. Key parts of the medical record that relate to various roles on the health care team are recording in the chart. The document also reviews policies around recording in patient charts, using abbreviations, and correcting errors. It discusses tools like the kardex for summarizing a patient's medical record and emphasizes not attempting care without reviewing these summaries first. The importance of accurately reporting observations and care provided to nurses and documenting in the medical record is also covered.

1. Chapter 6
Communicating with the
Health Team
Copyright © 2004 Mosby, Inc. All rights reserved.
Slide 1

2. Communication
• Open and honest communication is needed for a
successful partnership.
• Is the exchange of information
• For good communication:
– Use words that mean the same thing to the sender
and the receiver.
– Use familiar words.
– Be brief and concise.
– Give information in a logical and orderly manner.
– Give facts, and be specific.

3. Medical Record (Chart)
• The medical record is a written account of a
person's condition and response to treatment and
care.
• The record has many forms.
• Health team members record information.
• Agencies have policies about medical records.
– Policies generally cover abbreviations, signing
entries, and correcting errors.
• Parts of the medical record relate to your work.

4. Medical Record (Chart)
includes:
•
•
•
•
•
Admission sheet
Nursing history
Graphic sheet
Progress notes
Flow sheets
– ADL flow sheet

5. The Kardex
• Is a Type of Card File
• A summary of the Medical Record
• DO NOT ATTEMPT PATIENT CARE
WITHOUT *FIRST VIEWING THE
KARDEX

6. Reporting and Recording
• Agency policies:
– Abbreviations, Signing entries, and Correcting errors
• Report
– Your care and observations are reported to the
nurse.
• Record
–
–
–
–
–
Safety / Care
Measures what the client needed
What was observed
What was done
The person's response

7. Reporting and Recording
The 24-hour clock
• Ex: 11:42am would read as 1142
»
»
»
»
»
»
2100
1752
1313
2330
1615
1130

8. Medical Terminology and Abbreviations
• Medical terms are made up of parts of
words or word elements.
– Prefixes, roots, and suffixes
• Abdominal regions (quadrants)
• Directional terms (medial, lateral, inferior)
– Know abbreviations
– Know medical terms
– Know prefixes, root, and suffixes
• See page 72-73

9. Using Computers
• The right to privacy must be
protected.

10. Telephone Communications
•
•
•
•
Be professional and courteous.
Practice good work ethics.
Maintain patient’s privacy.
Follow the agency’s policy.

11. Dealing with Conflict
•
•
•
•
•
•
Define the problem.
Collect information.
Identify possible solutions.
Select the best solution.
Carry out the solution.
Evaluate the results.

12. THE
END